Detection of HIV-1 RNA in seminal plasma samples from treated patients with undetectable HIV-1 RNA in blood plasma

1. Detection of HIV-1 RNA in seminal plasma samples from treated patients with undetectable HIV-1 RNA in blood plasma Marcelin AG1, Tubiana R1, Lambert-Niclot S1, Lefebvre G1, Dominguez S1, Bonmarchand M1, Vauthier-Brouzes D1, Marguet F1, Peytavin G2, Poirot C1 and the Pitié-Salpêtrière AMP à risque viral Study Group 1 Hôpital Pité-Salpêtrière, Université Pierre et Marie Curie, Paris, France 2 Hôpital Bichat-Claude-Bernard, Université Denis Diderot, Paris, France

2. Background (I) • Recently, the Swiss Federal Commission for HIV/AIDS stated that a seropositive individual, with no other sexual transmitted disease (STD), under antiretroviral treatment and with an undetectable HIV-1 plasma viral load (< 40 copies/ml) for at least 6 months, does not sexually transmit HIV. • However, using a model-based analysis, it has been shown that the risk of HIV transmission in heterosexual partnerships in the presence of effective treatment is low but non-zero and that the transmission risk in male homosexual partnerships is higher over repeated exposures1. • Indeed, studies have shown that there is a strong relation between HIV plasma viral load and heterosexual transmission rates2. 1- Wilson et al. Lancet 2008. 2- Quinn et al. NEJM 2000.

3. Background (II) • However, HIV plasma viral load might not always reflect HIV replication levels in semen and some factors could increase the risk of transmission, such as: • Incomplete adherence • Variable drug penetration in compartments? • Other STDs • The aim of this study was to evaluate the residual HIV-1 RNA shedding in semen from patients who were enrolled in an assisted reproductive technology program (ART) .

4. Methods (I) • Since 2002, our clinical centre has managed HIV-1 serodiscordant couples within the male partner is infected and not the female to allow pregnancies with assisted reproduction techniques (ART) in order to: • Avoid the risk of HIV sexual transmission • In some cases, to treat infertility • For this purpose, before ART, sperm is “washed” and frozen until virological testing has shown the absence of HIV RNA detection.

5. Seminal plasma 10% 90% Sperm Density gradient centrifugation HIV-1 ARN detection Washing centrifugation Washed Spermatozoa 90% fraction Spermatozoa HIV-1 ARN detection Freezing Until ART

6. Methods (II) • 145 HIV-1 infected men attending the Pitié-Salpêtrière Hospital in the multidisciplinary ART program provided 264 paired blood and semen samples between January 2002 and January 2008. • The CobasTaqman HIV-1 Assay was used to quantify HIV-1 RNA in blood and in seminal plasma as previously described with a limit of quantification of 40 copies/ml in blood and 200 copies/ml in seminal plasma. • ARV pharmacological measurements were performed in blood and seminal plasma.

7. Results (I) • Among the total 264 paired samples: • 32 blood samples had HIV-1 RNA > 40 copies/ml • Median HIV RNA = 6325 copies/ml (range = 222 – 28300 cp/ml) • 16 seminal samples had HIV-1 RNA > 200 copies/ml • Median HIV RNA = 1770 copies/ml (range = 255 – 25100 cp/ml) • 234/264 paired samples were concordant: • 225 samples with undetectable HIV-1 RNA both in blood and semen (85.3 %) • 9 samples with detectable HIV-1 RNA in blood and semen (3.4%)

8. Results (II) • 30/264 paired samples were discordant: • 23 with detectable HIV-1 RNA in blood although the seminal viral load was undetectable • 7 with detectable HIV-1 RNA in seminal plasma although the blood viral load was undetectable

9. Results (III) • These 7 discordant paired samples corresponded to 7 distinct patients. • All these patients were under stable HAART with an undetectable HIV-1 RNA in blood plasma for at least 6 months and had no other STDs that are systematically screened in the program. • Among these 7 patients, 6 had an undetectable concordant result in blood and semen in at least one other time point during follow up.

10. When antiretroviral drugs such as lamivudine, tenofovir and indinavir were present in blood they were also detected in semen

11. Conclusions (I) • These results show that 5% of patients had detectable HIV-1 RNA in seminal plasma although they had concomitantly undetectable HIV-1 RNA in blood while they were under effective HAART and with no other STDs. • This does not seem to be related to a specific type of ARV treatment. • In these cases, HIV-1 RNA in seminal plasma is comprised between 255 to 1230 copies/ml. • This study confirms that HIV RNA shedding is intermittent in semen over time and that the rate of 5% should be considered as a low estimation of this phenomenon.

12. Conclusions (II) • Although, the presence of HIV-1 RNA does not mean necessarily infectious viruses, this result suggests that cell free virus can be still present in semen despite fully active ARV treatment. • These results should be taken into account in public health messages. • Indeed, while effective antiretroviral therapy is likely to substantially reduce HIV transmission at a population level, residual HIV RNA shedding can occur.

13. Conclusions (III) • Longitudinal studies should be conducted to measure more precisely the frequency and quantity of genital HIV shedding like those previously conducted for HSV. • Search for any relationship between the type of ARV use and the occurrence of viral shedding in a larger cohort of patients.

14. Acknowledgments • ART multidisciplinarygroup • InfectiousDisease: R. Tubiana, S. Dominguez, C. Katlama • InternalMedicine: M. Bonmarchand, A. Simon • Gynecology: G. Lefebvre, D. Vauthier, M. Dommergues • Reproductive biology: C. Poirot • Virology : V. Thibault, V. Calvez • Hepatology: P. Lebray • Pediatrics: I. de Montgolfier • Psychiatry: O. Rosenblum • This studywassupported in part by ANRS